People trying to lose weight and maintain the loss have mixed stories of success, so what's the most effective way to help them ultimately succeed?

And, what's the best way for services to be reimbursed?

Marshfield Clinic Research Institute researchers want to find answers through Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER), an innovative multi-site research study comparing three obesity treatment models in primary care practices in the rural Midwest.

The $10 million study, funded by the national Patient Centered Outcomes Research Institute (PCORI), is scheduled to conclude in 2020.

Marshfield Clinic researchers on this study are Research Scientist Jeff VanWormer, Ph.D., Center for Clinical Epidemiology and Population Health; and Marshfield Clinic Health System Endocrinologist Ram Pathak, M.D.Judith Hase, Center for Clinical Epidemiology and Population Health, is the local project manager.

Collaborators are clinicians and researchers from the University of Nebraska Medical Center and the University of Kansas Medical Center, the principal-investigator site. Together, researchers are testing three different weight management programs in rural Midwest primary care offices.

“Obesity is a medical condition that we can do something about, and we want people to improve their health and well-being," said Dr. VanWormer. “The U.S. doesn't have a primary care system that is well equipped to address obesity today. Few staff are trained in behavior therapy, and there is very limited time and reimbursement to provide obese patients with behavioral counseling, education and support."

About 30,000 Health System patients are morbid​ly obese “and there are limited options to help them in primary care, particularly in rural and underserved areas," Dr. VanWormer said. “RE-POWER is the biggest rural obesity trial in the United States, meant to discover the best ways to implement behavioral weight management solutions in primary health care settings.

“This can be done through scientifically-driven and patient-centered programs promoting healthy eating, physical activity, problem-solving and successful long-term weight control. The vast majority of obesity interventions are short – maybe six months – and over time people tend to gain back most of the weight lost. RE-POWER is a longer-term intervention with two years of follow-up. That's uncommon, but it's where the science in this area needs to go."

The rural Midwest was chosen because nearly 20% of the country's population lives in rural communities. Compared to their urban and suburban counterparts, rural residents have higher rates of obesity and obesity-related illnesses like diabetes, heart disease and arthritis.

Most rural communities have limited health care resources to treat obesity, so local primary care physicians are the primary means for treatment.

“It is important that we participate in research that translates into clinical practice," said Amit Acharya, B.D.S., Ph.D., executive director of the Research Institute. “RE-POWER is a great example of the research we are engaged in that is a priority for the rural community that our health system serves. Studies of this nature are a key element that the Research Institute brings in making our organization a learning health care system and adds significant value to the needs of our rural population."

About 1,600 men and women – 400 from Wisconsin – ​who receive health care from 40 rural primary care clinics in Iowa, Kansas, Nebraska and Wisconsin,  are participating in RE-POWER. Ten local Health System locations for the study include Colby/Abbotsford, Ladysmith, Merrill, Minocqua, Park Falls, Stratford, Wisconsin Rapids and three departments in Marshfield – Family Medicine, Internal Medicine and Med-Peds.

“It's been a good study so far that has brought research to other places in our system and they're really engaged in providing the direct patient contact," Dr. VanWormer said. “Personally it's satisfying to be in clinics that haven't participated in research before.

“There have been success stories too, with a number of patients waiting for something like this. Some have lost a lot of weight, and may need less medications for high blood pressure, cholesterol or blood sugar control. Hopefully those trends persist."

Each participating primary care clinic is randomly assigned to one of three possible weight management models:

  • Fee for service – primary care staff deliver individual weight management counseling, much like an individual medical appointment. Patients have brief one-on-one visits over two years. During the first six months, meetings are every week, then the frequency drops over time to once a month.
  • Patient-Centered Medical Home – a weight management specialist from the primary care practice provides education through group counseling in the primary care clinic.
  • Disease management – a weight management specialist delivers weight management coaching and education through group-based conference calls.

All participants are counseled on diet, exercise and behavior change strategies needed for sustainable weight loss. They meet with a health care professional at their clinic every six months to assess weight loss progress and track changes in blood pressure, blood glucose and cholesterol levels.

It will take time to see results, “but we're hopeful this study could mean long-term beneficial changes for our patients and how we approach weight management in clinical practice," Dr. VanWormer said.​